Healthcare Provider Details

I. General information

NPI: 1245274240
Provider Name (Legal Business Name): CARRIE J DYLLA PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 19TH STREET NE
WATERTOWN SD
57201
US

IV. Provider business mailing address

PO BOX 1030
WATERTOWN SD
57201
US

V. Phone/Fax

Practice location:
  • Phone: 605-886-8482
  • Fax: 605-884-4300
Mailing address:
  • Phone: 605-886-0123
  • Fax: 605-886-5447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0485
License Number StateSD
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number1052055
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: